Originally published in The Ottawa Citizen October 08, 2005

The word colic is enough to jar parents’ memories of sleepless nights and hours of frustration and angst trying to soothe their newborn. This particular newborn stage has no definitive treatment, hence there are myriad home remedies and suggestions to treat it.

Less than five per cent of all infants with colic have an underlying disease or disorder. A thorough history and physical exam can differentiate between colic and a disease state.

The incidence of colic varies from about five per cent to 25 per cent of infants. If your baby is gaining weight and has a normal physical exam, it is usually not necessary to perform any laboratory or diagnostic imaging tests.

Colic is usually defined by the “rule of three” — crying for more than three hours per day, for more than three days per week, and for more than three weeks in an infant that is well-fed and otherwise healthy. The inconsolable crying is unpredictable, begins without warning and without a specific cause.

Commonly during colic, the infant’s face flushes and the baby pulls his or her legs up toward the abdomen, clenches his or her fists and wails a high-pitched scream.

Normally most infants will cry about 2.2 hours a day. This peaks by six weeks and declines thereafter.

Dr. Tammy Clifford, director of epidemiology and researcher at CHEO’s Research Institute, and other colleagues published an article that supports the current understanding of colic: “It does not last long, nor does it have negative long-term effects on the mother’s mental health.”

Although studies have looked at gastrointestinal function and the home life of these babies, they have not been found to be causative factors. Many hypotheses are currently being investigated for cause, but none have provided conclusive evidence.

When looking at the crying cycle or patterns of infants, it seems that colicky infants are simply at the upper end of the spectrum in that they exhibit a similar but more intense crying pattern. These infants are more difficult to soothe and the crying lasts longer than seen in non-colicky infants.

In both groups, crying wanes by four months of age, implying that this is likely to be a normal neurological development process.

Parents who have concerns about their newborn should be prepared for some questions their physician or community health nurse may ask them:

• A description of the crying, when they cry and its duration.
• Do they spit up?
• Are they drinking or sucking well?
• Is there any vomiting or diarrhea?
• Do they have a change in breathing rates, an increased effort to breathe or turn blue when crying?
• Is the rectal temperature greater than 100.4 degreesF (38 degreesC)?

Keeping a log of the crying frequency, onset and duration is helpful to ascertain if there is a pattern or cycle.

What can you do to help alleviate infant colic? Given that colic spontaneously resolves, it is difficult to substantiate a consistent cause-and-effect relationship.

Breastfed infants should continue breastfeeding. There are some clinical trials suggesting that milk products, eggs, wheat and nuts be temporarily removed from the mother’s diet. Parents who smoke in the house or car should stop.

Studies that changed the formula of formula-fed babies were contradictory. Lactose-free formulas made no difference. Some babies switched to soy-based formula developed a soy protein allergy.

Simethicone (Ovol) is used to absorb stomach and intestinal gas. Several randomized, placebo-controlled, multicentre trial (RCTs) showed that simethicone was no better than a placebo in reducing the effect of colic.

Gripe Water may include any of a variety of herbs and herbal oils, such as cardamom, chamomile, cinnamon, clove, dill, fennel, ginger, lemon balm, licorice, peppermint and yarrow. It may also have added sugar and alcohol. The claim is that it reduces flatulence and indigestion, but these factors have not been conclusively associated with colic. If used, avoid the sugar and alcohol-containing product and ensure that it was produced in Canada or the United States.

There is weak evidence that herbal teas containing mixtures of chamomile, vervain, licorice, fennel, and lemon balm decrease crying in colicky infants. Parents should be cautious because of the lack of standardization of strength and dosage in many of these products and their potential to interfere with normal feeding cycles.

Various interventions aimed at decreasing crying in colicky infants have been equivocal. These include car-ride simulators, crib vibrators, infant carriers, early response to crying, gentle soothing motions, avoidance of overstimulation, pacifiers, prophylactic holding and carrying, infant massage and maintenance of day-night orientation. Chiropractic treatment has shown no benefit over placebo.

Counselling parents about these interventions did not produce any better result than providing support, advice and reassurance.

There is no association of asthma or allergies with colic. At one year of age, babies who had colic were not different from non-colicky babies. Colicky babies grow up normally.

Related articles:

1. Low-iron formula can slow development
2. The hazards of breastfeeding
3. Infant nutrition

Originally published in The Ottawa Citizen January 09, 2005
Original Title: Toxic Soup

All the ingredients for a potential health calamity are present

The tsunami survivors face great health challenges. To date there have not been reports of epidemics of cholera or other infectious diseases. However, the massive aid pouring into the affected regions is designed to address the health risks that have the potential to cause further harm.

All the ingredients for a potential health calamity are present: a contaminated water supply, lack of sanitation infrastructures, overcrowding, malnutrition, and endemic infectious diseases.

Human waste and decaying corpses contribute to the massive contamination. In effect, some of the survivors are living amongst a biologic toxic soup containing myriad pathogenic micro-organisms.

It is the children who will suffer most. Their weakened state impairs their ability to resist disease. Many can live without food for a week or more, but survival time is measured in days without clean water; they will rapidly succumb to dehydration, especially within the hot tropical environment.

With weakened immune systems comes an increased incidence of diarrheal illnesses, pneumonia, urinary tract infections and skin infections, among others. The severity of the illness and the survival rate is usually proportional to the time it takes to diagnose and treat it.

Indeed, bacterial diseases such as typhoid (Salmonella typhii), cholera (Vibrio cholerae), and enterotoxigenic E. coli are a major cause of dehydration, and are endemic in developing countries in Asia and Africa. All these organisms are found in contaminated food and water. They will also pass from person to person. Lack of adequate shelter makes it impossible to isolate the sick from the uninfected population.

Although the manner in which they cause disease (pathogenesis) differs, the end result is similar: They will infect and damage the intestines (enteric disease).

The small intestine absorbs most of the nutrients from food while the large intestine absorbs about 99 per cent of all water that flows through it. Damage to these structures can lead to bleeding and reduced absorptive capacity causing massive diarrhea.

Children and the elderly do not have as great a fluid reserve as do younger adults. In many instances, they must receive intravenous fluid replacement to compensate for their losses from diarrhea. The availability of clean water to drink will not help them in this case because the large intestine has lost its ability to absorb it.

The supportive care to treat cholera and other enteric diseases requires many litres of intravenous fluid replacement per patient. Some may need between 10 and 20 litres during the course of disease. Given the thousands of people that will contract these diseases, the resources alone for this one condition can strain available medical resources and supplies.

Contaminated pools of water attract disease-carrying flies, malaria and dengue fever-laden mosquitoes, and also harbour hepatitis A.

Without adequate shelter and netting for nighttime protection, the survivors are at risk for malaria and dengue fever. Left untreated, many will die. Waterborne parasites can also cause intestinal infection leading to cramps, bleeding and diarrhea. Most healthy people will recover from hepatitis A without any major consequences. However, the survivors of the tsunami have a greater risk of complications because of their weakened state.

Tuberculosis, a disease that affects two billion people worldwide — roughly one-third of the world’s population, most in developing countries — will claim more victims. This highly contagious person-to-person disease will have the opportunity to infect many others because of the living conditions and migration of people to temporary shelters or camps.

Some will have physical injuries that require proper wound care. Without treatment, these wounds will fester and infections will develop. Cellulitis is a common and potentially serious skin infection that normally starts in areas where there is pre-existing skin damage. The skin becomes swollen, red and hot and has a poorly defined border. The area of redness (erythema) rapidly expands and creeps along the skin within hours.

If diagnosed early, treatment consists of an oral antibiotic. Intravenous antibiotics are used if oral treatment fails or if there is an initial extensive spread of the infection. However, many of the survivors will not have access to prompt medical treatment. The end result is that a readily treatable infection will spread and increase the risk of septic shock and death.

The relief efforts are designed to counter the problems outlined, here. Setting up proper sewage and waste management systems will take time. Burying the dead, decontaminating water supplies, providing food and shelter and tending to the sick and injured are the initial focus of the recovery program. This in turn will slowly introduce order into a chaotic situation, but it will take months or years to remedy.

© Dr. Barry Dworkin 2005

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2. Have needle, will travel
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Originally published in The Ottawa Citizen September 7, 2004

Original Title: The heebee jeebee itch

With the beginning of the school year, cold viruses, potential allergens and other infections are ready to greet our children at the door.Although we handle these situations well, the anxiety meter reaches a crescendo when we face those nefarious villains: scabies and head lice (Pediculosis).

Mention that your child has head lice and watch your friends and family members slowly back away from you, start scratching their heads or bodies and run for the nearest door.

What can parents and schools do to prevent and treat these infestations? Where do they come from and how do infestations occur?

Let us enter heebie-jeebie territory.

Head lice (Pediculus humanus capitis) are one of three types of lice that live only on humans. The other two are pubic lice (Phthirus pubis or crabs) and body lice (Pediculus humanus corpus). Contrary to popular belief, these insects do not fly, jump or hop from person-to-person, nor are they related to poor hygiene and low socioeconomic status.

Head-to-head contact is the primary mode of transmission, although sharing hats, combs and brushes can do so as well. Three- to 11-year-old children are most susceptible, especially girls because of their social behaviour.

The infestation can start two or more weeks prior to the development of the allergic reaction and itch (due to the louse’s saliva). Children will frequently scratch their heads once the bugs have set up shop.

Detecting lice can prove difficult because they move rapidly. Indeed, many will see the lice eggs or nits — tiny oval-shaped blobs that stick out at an angle from the hair shaft. Nits can be confused with normal skin flakes or dandruff. Dandruff is brushed off the hair shaft whereas nits are glued in place.

Finding nits does not mean there is an active infestation. If microscopic examination of the nit shows it contains an embryo or you find at least one louse, then there is an active colony. All family members must be examined for lice under this circumstance.

Eradication of head lice includes a combination of mechanical removal of nits with a nit comb or brush, substances to asphyxiate them, certain antibiotics and/or an insecticide. The insecticides are toxic to the louse’s nervous system.

Solvents such as formic acid and white vinegar will dissolve the cement that holds the eggs on the hair shaft, enabling easier removal of the nits. Although it may create a bit of a mess, applying olive oil and wearing a shower cap for six hours per day for four consecutive days may kill the lice and nits. Using petrolatum (Vaseline) on eyelashes produces good results.

The treatment of choice is usually an insecticide such as permethrin (Nix or Rid shampoo). It is safe and effective, it can be used even by those who are pregnant. Suspect insecticide resistance if lice are found alive 24 to 48 hours after treatment. Your doctor will recommend another agent.

Given that lice survive for only a day if separated from the human host, a simple wash of recently worn clothes is all that is required. Vacuum the furniture, toys and other household objects. A complete scrub-down is unnecessary.

The scabies mite (Sarcoptes scabiei) shares some of the head louse’s characteristics: it is a human parasite and is transmitted by direct contact. However, it can survive up to four days away from its human host on clothing, bedding and upholstered furniture. Contact with any of these infested objects can result in the bug’s transmission.

It will burrow into the underarms, elbow creases, waist, groin, buttocks and feet to lay its eggs. These areas become intensely itchy from the louse’s excrement and a bumpy red rash can develop. Skin damage (excoriations) occurs from the intense scratching. Infants may demonstrate larger sores or bumps on their skin and have head and neck involvement.

Adults and children older than five years of age can use a five-per-cent solution of permethrin. After a bath or shower, the cream is applied from the neck down to cover the entire body surface. It is washed off after eight to 14 hours. One application has a cure rate of about 90 per cent. Although generally safe for use by pregnant women, breastfeeding should be delayed or halted until all residual cream is washed off the skin.

Treatment failures should be assessed by your doctor.

Itching and discomfort can continue for up to four weeks after treatment. Leftover pieces of the mites will remain buried under the skin until the skin regenerates and sloughs the debris away. Antihistamines can help treat the itch.

All clothes, linens, towels, and upholstered furniture used in the previous four days must be decontaminated or the cycle of infestation may recur.

More information can be found at HealthyOntario.com .

© Dr. Barry Dworkin 2004

Related articles:

1. The facts of lice life
2. Risk of recurrent head injuries in children
3. Childhood rashes hard to diagnose at first

Originally published in the Ottawa Citizen, August 10, 2004

Shortness of breath (dyspnea) strikes deep at a person’s self-preservation instincts. The fear of suffocation commonly leads to a feeling of panic. The ability to diagnose and treat the condition depends upon past medical history, the ability to gather a good medical history of the acute condition and prompt evaluation of the patient’s physical findings.

We will run through a template for your use to help you gauge you first course of action. Acute shortness of breath is best assessed in an emergency department setting because it is equipped to manage, treat, and diagnose the problem.

It is a parent’s nightmare to see there newborn child or infant struggle to breathe. The ensuing panic understandably clouds the parent’s ability to assess the situation. Often, patients or family members will call their doctor’s office or help-line for advice.

An infant that is in respiratory distress will have these signs:

1)      The skin between their ribs tugs inward (indrawing)

2)      The abdomen pops outward while their ribcage pulls inward with each effort to breathe inward, then the reverse happens (paradoxical breathing).

3)      There is indrawing at the semi-circular notch at the top of the breastbone (sternum).

4)      The nostrils flare in order to maximize air intake.

5)      The head bobs forward with each inspiration

6)      Grunting noises

There are six criteria to consider in children when they are short of breath:

• Are they less than three months of age?
• Did the dyspnea start suddenly?
• Does the child have a sore throat?
• Do they have a croupy cough (sounds like a barking seal)?
• Are they lethargic?
• Do they have a temperature of 38.8 ºC of 102 ºF?

Answering “yes” to one or more of these questions requires prompt emergency department evaluation. If all the answers are “no”, the child needs a same-day office visit to his or her doctor.

The most common causes of shortness of breath in children are lung infections like pneumonia, croup and infection and swelling of the smaller airways (bronchiolitis).

Adults have a different set of criteria to assess whether urgent care is required:

• Do they have severe dyspnea?
• Are they experiencing dyspnea at rest?
• Is this the first time they have felt short of breath at rest?
• Do they have a sudden onset of chest pain?

An affirmative answer to any one of these criteria requires an emergency department assessment. If the patient has a history of congestive heart failure or chronic obstructive pulmonary disease but answers “no” to the above questions they must inform his or her doctor and pay them a same-day visit to adjust the treatment regimen.

The causes of dyspnea in adults are legion: congestive heart failure (CHF) asthma attacks, chronic obstructive pulmonary disease (COPD), heart attack, foreign-body obstruction of the airways and panic attacks among the many other causes.

Some of the other causes of dyspnea are revealed by a thorough patient history and physical exam. For example, a severe sore throat that is associated with shortness of breath may be due to a swollen epiglottis. The epiglottis is a flap of tissue that acts as a protective shield by covering the entrance into the lungs when you swallow food. If it swells too much it can lead to an airway obstruction.

Each symptom or sign may relate to a specific cause of dyspnea. Asthma and pneumonia are linked with cough. A painful chest wall can direct the physician to think about a collapsed lung (pneumothorax), pneumonia, a blood clot in the lung (pulmonary embolism) or inflammation of the outer skin covering the heart (pericarditis).

Someone who suddenly wakes up at night and bolts upright to catch their breath, requires pillows to prop up his or her head because they cannot breathe if they lie down or has markedly swollen feet may be suffering from a sudden exacerbation of congestive heart failure.

Tobacco users are at risk of developing chronic obstructive lung disease, congestive heart failure and pulmonary embolism.

Indeed there is an interrelationship between all these signs and symptoms. It is imperative to assess shortness of breath symptoms quickly because some of the causes cause greater harm in a shorter time frame than others.

Related articles:

1. Iron Overload
2. Sunday House Call # 316, August 29, 2010
3. Sunday House Call #299, April 11, 2010

Originally published in The Ottawa Citizen March 6 , 2004

Original Title: Nighttime waterworks

Bedwetting or nocturnal enuresis affects more than 200,000 Canadians between the ages of five and 19. It occurs three times more often in boys than in girls. This problem causes great parental angst and distress. Children often feel humiliated and ashamed when it happens. They fear sleepover parties and the cruel teasing that inevitably arises should their secret be revealed.

The International Children’s Continence Society’s specific definition of nocturnal enuresis is “the involuntary loss of urine that occurs only at night. It is normal voiding that happens at an inappropriate and socially unacceptable time and place.”

Bedwetting is not the child’s fault. The brain’s pituitary gland produces a hormone called vasopressin. Vasopressin reduces the rate of urine production by the kidneys. When we sleep, vasopressin levels increase. Indeed, children under the age of five who wet the bed are not exhibiting nocturnal enuresis. Some have not yet ramped up nightly vasopressin production. By the time they are five years old, most children will be producing enough to prevent their urinary bladders from filling while they sleep.

Children with cognitive disabilities should reach a mental age of four years before considering this diagnosis.

About 15 per cent of five-year-olds continue to wet the bed. This drops to eight per cent for 12-year-old boys, four per cent for 12-year-old girls and one per cent at age 15. Family history helps keep this condition in perspective. Fifty per cent of children will wet the bed if one of their parents had the same problem during their childhood, and 80 per cent if both parents did. Bedwetting eventually stops in most children.

Nocturnal enuresis is thought to be due to a group of conditions with different causes. It is not usually a sign of kidney problems unless the child is having problems during the day as well. Some children may have urinary bladders that are too small. They will have difficulty holding in their urine. Psychological stressors stemming from family crises, loss of friends and moving, among others, are other factors. However, the majority of children are healthy.

As with any condition, a thorough medical history, physical exam and urine test are the first steps in the evaluation process. To make this diagnosis, the five- or six-year-old child should have two or more bed-wettings per month and children over the age of six at least once or more per month. They should not be having any problems during the day.

Contrary to popular perception, sleep studies demonstrate that bedwetters do not sleep any more deeply than children who do not wet the bed. They are not lazy or acting out in defiance. Punishing children for this problem will not change their behaviour. They are unable to control this problem by conscious effort.

Treatment options include behavioural conditioning methods and medication, if required. Medication should never be prescribed for children under five.

The best cure rate is seen using a bedwetting alarm that the child wears at night. As soon as he or she begins to wet the bed, the alarm sounds. The child wakes up and gets up to go to the bathroom or holds in the urine until later. This training may take about three to four months to succeed.

Desmopressin (DDAVP) is a well-tolerated medication that is similar to vasopressin and comes in pill and nasal spray format. Some studies indicate it works best in children at least nine years of age or older and in children who had few wet nights. The generally mild side-effects include nose irritation, nosebleeds and headache. The medication acts quickly to resolve nocturnal enuresis and is used for about six months. However, children may relapse after it is discontinued.

The combination of an alarm and medication is another strategy to help train the child.

What can you do to help your child?

* Your child needs your support and reassurance that you will help them overcome this problem.

* Have a positive outlook and avoid punishing your child for a condition that is not their fault.

* Do not allow your child to drink milk, juice, water or sodas within a few hours of their bedtime.

* If they do wet the bed, ask your young child to take the sheets off the bed. Your older child should be responsible for doing their laundry.

* Get into the habit of waking your child to go to the bathroom before you go to bed.

* A sticker reward system for dry nights works well for younger children. A prize is given once they reach a certain number of dry nights.

* Consult your doctor sooner rather than later if you suspect your child may have nocturnal enuresis.

© Dr. Barry Dworkin 2004

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2. What to look for if your infant or child shows signs of flu….
3. What happens when a child receives a double dose of H1N1 vaccine in error?

Originally published in The Ottawa Citizen August 12, 2003
Original Title: Low iron infant formulas

Dumb and dumber.

That’s what Dr. David Mack, chief of pediatric gastroenterology at the Children’s Hospital of Eastern Ontario, thinks about low-iron infant formulas.

“On the one hand,” he says, “formula companies are adding nutrients found in breast milk to promote the development of cognitive and visual development. Yet the lack of iron has the potential to thwart this development.”

The recent addition of two essential fatty acids, decosahexanoic acid (DHA) and arachidonic acid (ARA) into some formulas is a case in point. These fatty acids promote visual acuity and cognitive development in preterm and term infants and may be involved in other critical body functions.

It is ironic, Dr. Mack says, that these same companies would offer reduced-iron formulas. In a letter to Dr. Margaret Boland, chair of the nutrition committee of the Canadian Pediatric Society, Dr. Mack shares his concerns about this trend.

Pharmacies and grocery stores provide similar shelf space for low-iron cow milk-based formulas, he observes. Parents often do not notice that the product is low in iron content. There is also the perception that both types of formula provide equal benefit.

Parents will often change formulas either on their own accord or on the advice of their health care provider if their formula-fed child becomes more fussy, has cramping, colic, acid reflux from the stomach, flatulence or increased spitting-up. But there is no evidence that links formula-iron content with these conditions.

Dr. Mack notes that one of the first tendencies is to switch in error to a low-iron formula if there is a suspicion of an intolerance to cow-milk protein.

Within his practice, he often encounters the urban myth of iron causing infant constipation. However, this is actually rare. The infrequent bowel movements of soft stools result from inadequate intake of formula.

Switching to a low-iron formula further compounds the problem. The infant suffers an increased risk of iron deficiency anemia. This anemia, or reduction of oxygen transporting red blood cells, reduces the delivery of oxygen to the developing infant, especially the brain and nervous system. Iron-deficiency anemia is associated with problems in cognitive, behavioural and physical development in infants and children.

Some parents continue with low-iron-based formulas because hospitals stock and distribute them to parents for newborn feeds.

There are a few reasons why low-iron formula use is so common. Similar product packaging, poor labelling, a general lack of knowledge regarding the importance of iron in infancy and a lack of physician and nurse intervention are some of the reasons parents continue to use these products.

But there is no scientific evidence to support this product class.

There are no known medical contraindications to using iron-fortified formulas. Professional organizations do not advocate using low-iron formulas. Even the formula company representatives discourage its use.

“Public health policy successes include the introduction of iron-fortified infant formulas in the 1970s with the prevalence of iron-deficiency anemia being dramatically reduced,” Dr. Mack notes. However, Canadian infants and children are still at risk.

So why does this product remain on the store shelves? Dr. Mack believes sales of low-iron formula must still be significant enough to continue the product line.

With the exception of cow-based formulas, all other formula groups (i.e. soy-based, hydrolysate, amino acid) are iron-fortified.

Dr. Mack has six recommendations for the use and content of cow milk-based formulas. He asks the Nutrition Committee of the Canadian Society for Pediatrics to adopt and recommend these principles.

1. Infants who are not breast-fed or partially breast-fed should receive an iron-fortified formula.

2. Discontinue the manufacture of low-iron infant formula.

3. If low-iron infant formula continues to be available to consumers, the label must contain a health warning about the risk of iron deficiency anemia and its effects upon infant growth and development.

There must be consistent labelling practices akin to other formula groups (i.e. soy, hydrolyzed and amino acid). Manufacturers should remove the term ‘with iron’ from the front label. All listings including iron content should appear on the package nutrient content label.

4. The Hospital Association recommend to their members not to supply low-iron infant formula in their hospitals.

5. The distributors of low-iron infant formula should not provide shelf-space for low- iron infant formulas. A physician note would be required to obtain low-iron infant formula.

6. The Canadian Pediatric Society and formula manufacturers continue to provide education for the public and for health care providers regarding iron and infant growth and development.

If no one buys the product, companies will not sell it. It’s one way consumers can influence health outcomes and corporate behaviour.

Related articles:

1. Infant nutrition
2. Iron Overload
3. Consuming the nutrients you need

Originally published in The Ottawa Citizen July 2, 2003
Original Title: Sweat Shops

The effects of this current heat wave and high humidity levels are particularly dangerous for children and the elderly. Children have parents who oversee their well-being and protection from the elements. Many elderly people on the other hand do not have this level of care. They remain confined to their residences, nursing homes or apartments, some without the benefit of air conditioning.

What specific difficulties are encountered with age as it relates to heat regulation? The normal response to heat overload is a ramping-up of the body’s heat dissipation mechanisms.

Normally, heart rate increases to deliver more blood to the blood vessels on the skin surface where heat dissipates. The skin will lose heat through the processes of evaporation of sweat, air convection, heat conduction and radiation. These processes are less efficient with the current weather conditions.

The elderly have a decreased thirst response. They are at risk of not replenishing water lost through sweating. With this week’s temperatures it is not unreasonable to assume a loss of a litre of sweat every one or two hours. This rate increases with physical exertion or activity.

Many elderly people are on some type of medication that can increase the risk of heat stroke and dehydration. Diuretics such as hydrochlorothiazide and furosemide (Lasix) are commonly used to treat hypertension and congestive heart failure among other disorders. They promote salt and water loss through their affect on the kidneys.

Alcoholic and caffeinated beverages also have diuretic properties. The use of laxatives, especially the harsher agents can augment fluid loss.

They will rapidly dehydrate should they not adequately replace their fluid loss. Their blood volume will contract because of the water loss. Less blood will flow to the skin surface reducing heat transfer to the skin surface. A reduction of sweating ability compounds the problem.

With age, blood vessels do not dilate efficiently (vasodilatory response).Heart medications such as beta-blockers and certain calcium channel blockers can reduce heart rate and blood pressure reducing the capacity to circulate blood. The elderly’s maximum heart rate is much less compared to a younger adult further reducing blood flow to the skin. This also reduces the body’ ability to dissipate heat from the skin surface.

The elderly tend to be less fit and are not as mobile as younger folks. Some are bedridden or so incapacitated that they have difficultly replenishing their fluid supply. It can be difficult to get to the kitchen.

Since many of the elderly remain indoors, it is difficult to know who needs help. If you suspect someone is at risk, please check up on them. If you live in a non air-conditioned apartment complex and are uncomfortable from the heat be very aware of your risk. Knock on your elderly neighbour’s door to ensure they are safe.

This week’s temperatures and humidex will cause heat gain via heat radiation into the body. Humidity interferes with sweat evaporation. The end result can be swelling, heat cramps, fainting, heat exhaustion and heat stroke.

General recommendations for prevention include:

* Stay in air conditioning if possible.
* Drink lots of water before, during and after any outdoor activity.
* Avoid drinks with caffeine or alcohol. They are diuretics that will increase fluid loss via urination.
* Take a lot of rest breaks if you must go outdoors in hot weather.
* Avoid direct sunlight and stay in the shade when you can.
* Wear light-coloured, loose-fitting, open-weave clothes.
* Change wet clothes.
* Try to schedule activities early in the morning or late in the evening.
* Avoid heavy outdoor activity between 10 a.m. and 6 p.m., when the sun is hottest.

Source: American Family Physician

Please contact your doctor if you have questions about your medication use during this heat wave.

Related articles:

1. Know the facts about heat-related illness
2. Don’t Sweat the Small Stuff
3. A primer on heat-related illness as Ottawa experiences its first heat wave of the season

Originally published in The Ottawa Citizen April 29, 2003

Original Title: The big gaping maw

As warmer weather approaches, children will be spending more time playing outdoors. So will dogs.

Although there are dog leash laws in Ottawa and the majority of dog owners are responsible, dog bites remain the most common animal bite seen in our hospitals. The Canada Safety Council estimates there are 460,000 dog bites in Canada every year, almost half of them involving children.

The Canadian Hospitals Injury Reporting and Prevention Program states animal bite injuries account for one per cent of all emergency room visits, with dogs accounting for 85 per cent of all these wounds.

Boys five to nine years old sustain the most dog bites –they account for 28.5 per cent of all bitten people. And almost one-third of the time, bites occur between 4 p.m. and 8 p.m. during summertime.

The victim usually knows the dog. Eighty-five per cent of all dog and cat bites come from the family’s or a neighbour’s pet. Thirty-four per cent of attacks occur at the victim’s home and 30 per cent at a friend’s house. Provoking the animal accounts for half of all bite attacks.

Our children are more susceptible to serious injury because they are lower to the ground. Head, face and neck bites account for 70 per cent of the cases. Forty per cent of all bites in children are facial.

Over half of all attacks were minor requiring little treatment. A third needed medical follow-up after leaving the emergency department and one in 20 required admission to hospital.

The wound care for dog and cat bites vary. Dog bites cause lacerations, punctures and crush injuries. Cat bites commonly puncture the skin. Cat bite punctures have a high risk of bacterial infection; three to 18 per cent of dog bites become infected versus 28 to 80 per cent of cat bites.

There are several initial steps to care for a dog or cat bite. First, use soap and water and gently wash the wound.

Use a clean towel when applying direct pressure to stop the bleeding of the injured part. Apply a sterile bandage to the wound.

To reduce swelling and prevent infection, try to keep the injured part raised above the level of the heart.

Consult your doctor no later than eight to twelve hours after the bite injury for an evaluation. It may require oral antibiotic therapy. Report the incident.

Cat bites (not scratches) warrant a visit to your doctor because of their high risk of infection. Deep or gaping lacerations, bites to the hand, foot or head or any signs of infection like swelling, worsening pain, a spreading area of redness, fever or oozing of pus from the wound require immediate attention. Seek medical advice and treatment if the bleeding does not stop despite 15 minutes of direct firm pressure or if you suspect nerve damage, broken bones or a severe soft tissue crush injury.

People with underlying medical conditions that compromise their body’s wound healing capability such as cancer, lung disease, diabetes, liver disease or hepatitis, AIDs or other conditions that weaken the ability to fight infection should consider every bite as serious and warranting medical attention.

Your doctor’s approach to any bite injury is to ascertain the risk of infection, clean and remove any damaged tissue (debride the wound) if necessary and to determine whether to stitch it closed or leave it open to heal. The doctor will explore the wound to determine if there is damage to deeper structure like nerves and tendons.

Deep penetrating cat bites through joint spaces, bones or tendons, bites to the face, hands, feet and genitalia and wounds requiring surgical repair usually need an oral antibiotic to prevent infection.

Antibiotic ointments like Fucidin and Bactroban work well for dog and cat bite wounds with low risk of infection. Get a tetanus vaccine booster if your last one was more than five years ago. It is best to schedule a follow-up visit one to two days after the initial assessment.

If the injury is severe, the wound fails to heal or the infection spreads despite oral antibiotics, you will likely require hospitalization. In these cases, intravenous antibiotics and an assessment from a plastic surgeon is usually in order.

Rabies shots are rarely required for dog and cat bites. The decision to vaccinate against rabies is a concern of the public health department and the medical officer of health.

Preventing animal bites continues to be an area in need of improvement. Young children need constant supervision in the presence of any pet. Animals that are eating, fighting amongst themselves or appear sick should be left alone.

When choosing a dog, pick a family-friendly dog. Veterinarians, professional dog breeders or dog trainers are an excellent resource.

© Dr. Barry Dworkin 2003

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2. Skin infections need specific treatments
3. Hand infections need immediate attention

Originally published in The Ottawa Citizen April 15, 2003
Original Title: When to use an EpiPen

A recent pharmacist’s study presented to the Canadian Society of Allergy and Clinical Immunology indicates 63 per cent do not know how to use an EpiPen and 62.5 per cent cannot recognize the signs and symptoms of a severe allergic reaction (anaphylaxis).

Medications (penicillin, nonsteroidal anti-inflammatory drugs and aspirin, chemotherapy agents and angiotensin-converting enzyme inhibitors (ACEs)), bee and wasp stings, milk, seafood, nuts, blood transfusions, exercise and other chemical agents can trigger anaphylaxis.

The most common food allergies children develop in their first three years of life are to cow’s milk, peanuts, soy, eggs, shellfish and wheat. Peanuts, nuts and fish tend to be lifelong.

Two cell types, mast cells and basophils, are responsible for the allergic response. It is unknown why the response varies between people. Some develop a few hives or itchy skin whereas others develop a life threatening condition when the mast cells and basophils release abnormal quantities of chemical substances including histamine.

The blood vessels will dilate and leak fluid into the surrounding tissue causing swelling (angioedema) of the skin. Severe fluid loss leads to a collapse of the circulatory system.

The smooth muscle rings that encircle the airways (bronchi) will constrict. The airways themselves will produce copious amounts of mucous. The combination of these two effects plugs the airway making it impossible to breathe. Fluid can accumulate within the lungs leading to heart failure.

These and other reactions usually develop within five to 60 minutes after exposure. There can be a delay of one to eight hours before anaphylaxis occurs so vigilance is a priority.

The symptoms include:

• Itching, flushing, hives and swelling of the skin and sweating
• Itching, tearing and swelling of the tissues around the eyes
• Nasal congestion, runny nose, sneezing and a metallic taste in the mouth
• Difficulty breathing, wheezing, increased airway secretions and mucous production, swelling of the upper throat, blueness of the skin (cyanosis), hoarse voice, sounds of laboured breathing and a choking sensation
• Very rapid or very slow heart beat, an irregular heart beat, low blood pressure and cardiac arrest
• Nausea, vomiting, abdominal cramps, bloating and diarrhea
• Dizziness, weakness, fainting, a fear of impending doom and seizures
• Ninety per cent of people with allergic reactions have hives and skin swelling after feeling itchy, flushed and fearing impending doom.

Breathing difficulties occur in 50 per cent of these people especially those with asthma. Gastrointestinal symptoms and extremely low blood pressure (anaphylactic shock) occurs in 30 per cent.

Five to 20 per cent of people may have an initial allergic reaction that resolves but recurs one to eight hours later. Be on guard for this phenomenon. This happens when a person develops symptoms 30 minutes after exposure and in those orally ingesting the substance.

People at greatest risk of anaphylaxis have a history of asthma, eczema, allergic rhinitis (nasal allergies) and hives. Injection and intravenous administration of the allergen is likely to be more severe than if swallowed. Inhalation can provoke a response.

In the event of anaphylaxis, epinephrine will give you 15 to 20 minutes to get to an emergency room. Epinephrine counters the allergic response by constricting the blood vessels, relaxing the smooth muscle of the airways to improve breathing, stimulating the heartbeat, and reversing hives and swelling about the face and lips. Antihistamines will not reverse anaphylaxis fast enough to make a difference.

Emergency epinephrine provided in the EpiPen format is a spring-loaded syringe containing a pre-measured dose of epinephrine. A junior format is available for children weighing under 15 kilograms or 33 pounds.

To use the EpiPen follow these directions.

1. Slide the protective plastic sleeve off the unit
2. Remove the gray safety cap. Do not touch the black plastic tip.
3. With your dominant hand hold the EpiPen and position the black tip against the fleshy outer portion of the thigh. Keep all fingers clear of the black tip.
4. Push the pen against the thigh for five to ten seconds. Massage the area after the injection. Pain is minimal
5. A needle sticking out the end of the pen after you are done indicates proper delivery of the medication into the skin
6. Call 911 or seek emergency medical assistance.

You can inject through thin clothing if need be. View an animated version of EpiPen technique at www.epipen.com. The Calgary Allergy Network is another source of information (http://www.calgaryallergy.ca/Articles/epipen.html).

Your pharmacist can demonstrate how to use the EpiPen. An Ottawa company, Allergy Essentials (www.allergy-essentials.com) sells EpiPen trainers (fully functional without the needle for $6.50). Please take the few minutes to learn to save the time of your life.

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Originally published in The Ottawa Citizen October 15, 2002
Original Title: Daycare Part III: A little red in the face

Part I – Why children fight one cold after another
Part II – Children’s eye diseases spread quickly

What are the common childhood rashes seen in the school and daycare setting? Initially, many rashes can look the same, which can sometimes make identification difficult. Rashes eventually branch off in their own direction within a day or two prompting the doctor to say “Aha! I knew what it was happening all along!” This is something akin to what your investment broker says to you now.

Roseola is a viral rash usually seen in children between six and 24 months of age. These children do not appear ill but can have a low-grade fever for a few days. In rare cases, children can develop high fever and febrile seizures. Once the fever breaks, the rash appears as small red spots scattered on the face and body that last a day or two. It is not very infectious and there is no specific treatment.

Hand, Foot and Mouth disease most often affects young children but can appear at any age. It is an infectious viral illness spreading from person to person by air or touch. It occurs more commonly in the summer and fall. It will incubate for ten to 14 days before the start of symptoms. Although usually not severe, it does cause fever, headaches, loss of appetite, diminished activity and energy levels, sore throat and a particular rash.

Small red spots with a blister on top appear on the hands and feet and sometimes on other body parts. There can be painful mouth ulcers. The rash lasts seven to ten days. Children remain infectious one to two weeks after the onset of the illness. There is no specific treatment. Children can return to school or daycare once they feel up to participating in normal activities.

Fifth disease commonly referred to as Slapped Cheeks Syndrome occurs in school-aged children. One to four days before the onset of rash, the child may have had a cold-like illness. Some children will have a headache, sore throat, runny nose, itchiness, nausea, diarrhea and vomiting, joint pain and sore eyes. The range of occurrence of these symptoms runs on average between zero to 50 percent.

It starts as a dark red rash on the cheeks that looks like the face was slapped. By the time the rash develops, the child usually feels better. A rosy red lacy rash appears on the arms and body that can come and go over a period of one to three weeks. There is no specific treatment. They are no longer infectious once the rash appears. Children can return to school when they feel better.

Chicken pox, despite the popular misconception, is not a benign disease. Caused by the Varicella Zoster virus, its complications include skin and soft tissue infection, ear, eye, nose and throat infections, serious bacterial infections like necrotizing fasciitis (“flesh eating disease”), pneumonia, encephalitis and meningitis. In Canada, 2000 children were admitted to hospital last year and 12 died.

Chicken pox has an incubation period of eight to 13 days after viral exposure. It spreads through the air and by direct contact with the blisters.

It starts with a fever for the first two days. Thereafter the classic “fried egg” blisters appear (a red circular spot with a blister in the centre) on the skin. An average of 350 blisters will erupt on the child’s body.

If you think the child has chicken pox or if indeed they do, isolation from pregnant women who have never had chickenpox is important because the virus can damage the fetus. There is no danger to pregnant women who are immune to the virus.

Do not give aspirin (Acetylsalicylic Acid (ASA)) or any products that contain ASA to a child with chicken pox. They can develop Reye’s syndrome that can damage the liver and brain. Use Acetaminophen (Tylenol or Tempra) instead.

Good gentle skin hygiene will help prevent bacterial infections of the pox blisters. Scrubbing the skin can promote infection and scarring. Antihistamines (Claritin, Benadryl) and Aveeno bath powder can help relieve the itch. Calamine lotion is ineffective.

After a chicken pox infection, the virus can lie dormant in the body for years. Once reactivated, it will cause Shingles, a large painful blistered rash on a segment of your body or face with its own set of painful and damaging complications.

What can we do to prevent some of the illnesses reviewed over these past three weeks? Good hygiene and disinfecting toys reduces contagion. However, this is a Herculean task in a room full of toddlers and young children. Some diseases warrant isolating the child during their contagious period. There are vaccines available that can reduce the risk of some of these diseases.

Varivax will protect children from chicken pox. Over 20 million doses and 28 years of experience show long-lasting immunity. Ninety-five percent of children will become immune six weeks after vaccination.

Prevnar will reduce the rate of ear infections and pneumonia caused by the bacteria Streptococcus pneumoniae. It is the most common cause of ear infections, pneumonia and meningitis in infants and toddlers. Menjugate vaccine will protect children from another type of meningitis.

All children that follow the routine vaccination schedule receive the Pentacel vaccine. One component of it protects infants and children against the bacteria Hemophilus influenzae that causes ear infections and pneumonia.

Your doctor can provide more information on your next well-child visit. The only thing infectious in your child should be their smile. May they all be happy and healthy.

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